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Rodrigues PSM, Shimano MM, de Oliveira E, Kawamura FM, Silveira AF, José Luvizutto G, de Souza LAPS. Adaptation and clinical application of assistive device chair for bedside sitting in acute stroke phase: two case reports. Disabil Rehabil Assist Technol 2024; 19:1272-1278. [PMID: 36630593 DOI: 10.1080/17483107.2023.2166600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/16/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
PURPOSE This report presents the adaptation of an assistive device chair for bedside sitting and its application in two patients with trunk control impairment in the acute stroke phase. MATERIALS AND METHODS The device was built with polyvinylchloride (PVC) pipes and designed by a team of mechanical engineers and physiotherapists to maintain a prolonged sitting position with less demand from therapists. To test the device, two patients were followed up during the acute phase of stroke. Both patients underwent an early mobilization program (30 min, twice a day, for three days) with an assistive device chair for bedside sitting. Patients were evaluated using the National Institutes of Health Stroke Scale (NIHSS), Trunk Impairment Scale (TIS), and International Classification of Functioning, Disability, and Health (ICF) checklist (b: body function; d: activity and participation). RESULTS The adaptations generated the following equipment: 1) foldable, 2) three levels of backrest inclination, and 3) a safety anterior support or an activity table. Both patients showed clinical improvement after the intervention period, with NIHSS score reduction, TIS improvement, and greater functionality and independence on the ICF framework. CONCLUSION The equipment with adaptations seems to be functional, easy to handle, and can potentially contribute to clinical and functional improvements in patients with trunk control deficits after stroke.
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Affiliation(s)
| | - Marcos Massao Shimano
- Department of Mechanical Engineering, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Edimar de Oliveira
- Student of the Mechanical Engineering, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Fábio Masao Kawamura
- Student of the Mechanical Engineering, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Ana Flávia Silveira
- Doctorate Student in Physiotherapy, Federal University of São Carlos, São Carlos, Brazil
| | - Gustavo José Luvizutto
- Department of Applied Physiotherapy, Federal University of Triângulo Mineiro, Uberaba, Brazil
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2
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Wei X, Sun S, Zhang M, Zhao Z. A systematic review and meta-analysis of clinical efficacy of early and late rehabilitation interventions for ischemic stroke. BMC Neurol 2024; 24:91. [PMID: 38459477 PMCID: PMC10921695 DOI: 10.1186/s12883-024-03565-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 02/12/2024] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION At present, stroke has become the first cause of death and disability among Chinese adults. With the coming of the aging population in China, the disease burden brought by stroke will be increasingly aggravated. And stroke is a leading cause of disability. There is a golden plastic period after stroke, during which timely and safe intervention and rehabilitation therapy can effectively improve the disability status. However, there is still controversy about the duration of interventional rehabilitation after stroke. This study conducted a meta-analysis on the influence of intervention in early and late ischemic stroke rehabilitation. METHOD Chinese language databases such as CNKI, Wanfang, and VIP, and English language databases such as Embase, PubMed, Web of Science, and The Cochrane Library were searched, and RCT related to early and late rehabilitation of ischemic stroke from the establishment of the database to October 2023 was collected. Review Manager 5.4.1 was used for relevant analysis. The main outcomes were Barthel Index or Modified Barthel Index, Fugl-Meyer Assessment scale, NIHSS, China Stroke Scale. Standardized Mean Difference (SMD) was used as an effective indicator of continuity variables, and the estimated interval was expressed by 95% confidence interval (CI). RESULTS A total of 1908 patients were included in 16 studies. The results showed that, compared with late rehabilitation, early rehabilitation improved clinical efficacy. Barthel Index or Modified Barthel Index score was [SMD = 1.40, 95%CI(1.16,1.63), p < 0.001]; the score of Fugl-Meyer Assessment Scale was [SMD = 1.18, 95%Cl (0.85, 1.52), P < 0.001]; the score of NIHSS was [SMD= -0.44, 95% CI(-0.65, -0.24), P < 0.001]; the result of China Stroke Scale score was [SMD= -0.37, 95%CI(-0.56, -0.18), P < 0.001]. CONCLUSION In comparison with late rehabilitation, early rehabilitation can significantly improve self-care abilities, daily activities, and neurological functions of ischemic stroke patients. TRIAL REGISTRATION This meta-analysis has been registered with Prospero, and the registration number is CRD42022309911. The registration period is March 22, 2022.
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Affiliation(s)
- Xufang Wei
- Hainan Medical University International School of Public Health and One Health, Haikou, Hainan, China
| | - Shengtong Sun
- Hainan Medical University International School of Public Health and One Health, Haikou, Hainan, China
| | - Manyu Zhang
- Department of Neurology, First Affiliated Hospital, Hainan Medical University, Haikou, Hainan, China
| | - Zhenqiang Zhao
- Department of Neurology, First Affiliated Hospital, Hainan Medical University, Haikou, Hainan, China.
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Shahid J, Kashif A, Shahid MK. A Comprehensive Review of Physical Therapy Interventions for Stroke Rehabilitation: Impairment-Based Approaches and Functional Goals. Brain Sci 2023; 13:brainsci13050717. [PMID: 37239189 DOI: 10.3390/brainsci13050717] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Stroke is the fourth leading cause of mortality and is estimated to be one of the major reasons for long-lasting disability worldwide. There are limited studies that describe the application of physical therapy interventions to prevent disabilities in stroke survivors and promote recovery after a stroke. In this review, we have described a wide range of interventions based on impairments, activity limitations, and goals in recovery during different stages of a stroke. This article mainly focuses on stroke rehabilitation tactics, including those for sensory function impairments, motor learning programs, hemianopia and unilateral neglect, flexibility and joint integrity, strength training, hypertonicity, postural control, and gait training. We conclude that, aside from medicine, stroke rehabilitation must address specific functional limitations to allow for group activities and superior use of a hemiparetic extremity. Medical doctors are often surprised by the variety of physiotherapeutic techniques available; they are unfamiliar with the approaches of researchers such as Bobath, Coulter, and Brunnstrom, among others, as well as the scientific reasoning behind these techniques.
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Affiliation(s)
- Jawaria Shahid
- Department of Physical Therapy, Ikram Hospital, Gujrat 50700, Pakistan
- Center of Physical Therapy, Rayan Medical Center, Gujrat 50700, Pakistan
| | - Ayesha Kashif
- Department of Senior Health Care, Eulji University, Uijeongbu 11759, Republic of Korea
| | - Muhammad Kashif Shahid
- Research Institute of Environment & Biosystem, Chungnam National University, Daejeon 34134, Republic of Korea
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Bahouth MN, Deluzio S, Pruski A, Zink EK. Nonpharmacological Treatments for Hospitalized Patients with Stroke: A Nuanced Approach to Prescribing Early Activity. Neurotherapeutics 2023; 20:712-720. [PMID: 37289401 PMCID: PMC10275818 DOI: 10.1007/s13311-023-01392-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 06/09/2023] Open
Abstract
Stroke remains a leading cause of adult disability. To date, hyperacute revascularization procedures reach 5-10% of stroke patients even in high resource health systems. There is a limited time window for brain repair after stroke, and therefore, the activities such as prescribed exercise in the earliest period will likely have long-term significant consequences. Clinicians who provide care for hospitalized stroke patients make treatment decisions specific to activity often without guidelines to direct these prescriptions. This requires a balanced understanding of the available evidence for early post-stroke exercise and physiological principles after stroke that drive the safety of prescribed exercise. Here, we provide a summary of these relevant concepts, identify gaps, and recommend an approach to prescribing safe and meaningful activity for all patients with stroke. The population of thrombectomy-eligible stroke patients can be used as the exemplar for conceptualization.
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Affiliation(s)
- Mona N Bahouth
- Department of Neurology, Johns Hopkins School of Medicine, 600 N Wolfe St; Phipps 486, Baltimore, MD, 21287, USA.
| | - Sandra Deluzio
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, USA
| | - April Pruski
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, USA
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Mariana de Aquino Miranda J, Mendes Borges V, Bazan R, José Luvizutto G, Sabrysna Morais Shinosaki J. Early mobilization in acute stroke phase: a systematic review. Top Stroke Rehabil 2023; 30:157-168. [PMID: 34927568 DOI: 10.1080/10749357.2021.2008595] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early mobilization is defined as out-of-bed activities in acute stroke phase, and has led to improvements in functional capacity and reduction of complications after stroke. OBJECTIVE This study aimed to investigate the effectiveness and safety of early mobilization in the acute stroke phase. METHODS This was a systematic review. We searched for studies with the keywords: "Stroke," "Early mobilization" and "Functional outcomes." Data source: NLM, LILACS, MEDLINE, PEDro, and Science Direct. Studies published up to June 2020 were included; (b) study eligibility criteria: clinical trials; (c) participants: stroke patients in the acute phase; (d) interventions: early mobilization; (e) study appraisal: two authors independently assessed the risk of bias, Grading of Recommendations Assessment, Development and Evaluation, and the Oxford Center for Evidence-Based Medicine Levels of Evidence. The safety was evaluated based on related and non-related adverse effects. RESULTS Altogether, 476 studies were retrieved. After exclusion, seven studies involving 8663 patients were included in the qualitative synthesis. The main activities were elevation of the headboard, sitting, standing, and walking. The most important outcome assessed was the modified Rankin scale score (disability) after 3 months of stroke, and two studies showed that early mobilization improves functional capacity after stroke. CONCLUSION the optimal time to start early mobilization is > 24 h of stroke according to hemodynamic stability and safety criteria. The duration of mobilization is recommended between 15 and 45 minutes, divided into one, two, or three times a day. The focus of early mobilization should be on sitting, standing, and walking activity.
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Affiliation(s)
| | - Viviany Mendes Borges
- Intensive Care Unit, Clinical Hospital of the Federal University of Uberlândia, Uberlândia Minas Gerais Brazil
| | - Rodrigo Bazan
- Professor of Department of Neurology Psychology and Psychiatry, Botucatu Medical School (UNESP), Botucatu São Paulo Brazil
| | - Gustavo José Luvizutto
- Professor of Department of Physical Therapy, Federal University of Triângulo Mineiro, Uberaba, Minas Gerais Brazil
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Wang W, Wei M, Cheng Y, Zhao H, Du H, Hou W, Yu Y, Zhu Z, Qiu L, Zhang T, Wu J. Safety and Efficacy of Early Rehabilitation After Stroke Using Mechanical Thrombectomy: A Pilot Randomized Controlled Trial. Front Neurol 2022; 13:698439. [PMID: 35463135 PMCID: PMC9028453 DOI: 10.3389/fneur.2022.698439] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background Early rehabilitation (ER) has been reported to be both safe and feasible for patients' post-stroke. To date, however, ER-related outcomes concerning patients who have undergone mechanical thrombectomy (MT) have not been investigated. This study aimed to determine the feasibility of ER and whether it improves prognosis in such patients. Methods In this single-center, double-blinded, randomized controlled study involving 103 patients who met the study criteria (i.e., has undergone MT), we randomly divided patients (1:1) into ER and conventional rehabilitation groups. The primary outcome was mortality, while secondary outcomes included favorable outcomes (modified Rankin scale of 0–2), the incidence of non-fatal complications, and Barthel Index (BI) scores. We assessed outcomes at 3 months and 1-year post-stroke. Results No significant between-group differences were found in terms of mortality and favorable outcomes at 3 months and 1-year post-stroke. At 3 months, 15 (28.8%) patients in the ER group and 29 (56.9%) in the conventional rehabilitation group (p = 0.002) had non-fatal complications. The BI in the ER and conventional rehabilitation groups was 100 (85–100) and 87.5 (60–100), respectively, (p = 0.007). At 1 year, the incidence of non-fatal complications was similar between both groups [BI in the ER group, 100 (90–100), p = 0.235; BI in the conventional rehabilitation group, 90 (63.8–100); p = 0.003]. Conclusion Early rehabilitation (ER) reduces the incidence of early immobility-related complications and effectively improves patients' activities of daily living on a short- and long-term basis. Our results indicate that MT contributes to ER in patients with stroke. Clinical Trial Registration www.chictr.org.cn, identifier: ChiCTR1900022665.
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Affiliation(s)
- Wei Wang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Department of Neurorehabilitation and Neurology, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, China
| | - Ming Wei
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yuanyuan Cheng
- Department of Rehabilitation, Tianjin Huanhu Hospital, Tianjin, China
| | - Hua Zhao
- Department of Rehabilitation, Tianjin Huanhu Hospital, Tianjin, China
| | - Hutao Du
- Department of Rehabilitation, Tianjin Huanhu Hospital, Tianjin, China
| | - Weijia Hou
- Department of Rehabilitation, Tianjin Huanhu Hospital, Tianjin, China
| | - Yang Yu
- Department of Rehabilitation, Tianjin Huanhu Hospital, Tianjin, China
| | - Zhizhong Zhu
- Department of Rehabilitation, Tianjin Huanhu Hospital, Tianjin, China
| | - Lina Qiu
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Department of Neurorehabilitation and Neurology, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, China
| | - Tao Zhang
- Department of Intensive Care Unit, Tianjin Huanhu Hospital, Tianjin, China
| | - Jialing Wu
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Department of Neurorehabilitation and Neurology, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, China
- *Correspondence: Jialing Wu
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Lv Y, Sun Q, Li J, Zhang W, He Y, Zhou Y. Disability Status and Its Influencing Factors Among Stroke Patients in Northeast China: A 3-Year Follow-Up Study. Neuropsychiatr Dis Treat 2021; 17:2567-2573. [PMID: 34393485 PMCID: PMC8357400 DOI: 10.2147/ndt.s320785] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/12/2021] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To explore the rate of post-stroke disability and its associated factors in the third year following discharge from inpatient rehabilitation in Northeast China. DESIGN A prospective cohort study. METHODS A total of 522 persons who were hospitalized with a diagnosis of stroke were recruited consecutively between April 2015 and December 2015 and followed for 3 years. The primary outcome was disability, which was assessed using the Modified Barthel Index (MBI), a cutoff score of ≤95 indicates disability. Plausible risk factors of disability were selected from available variables to perform multivariate logistic regression analysis. FINDINGS The proportion of post-stroke patients with disability decreased from 63.8% to 46.7% at 3-year follow-up. The factors associated with post-stroke disability were age, neurological deficits, cognitive function, depression, and social support. CONCLUSIONS/CLINICAL RELEVANCE Disability continues to be a significant issue for individuals after a stroke, and community health workers should perform targeted assessments and interventions to decrease disability, and pay special attention to individuals who are at greatest risk of post-stroke disability.
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Affiliation(s)
- Yumei Lv
- School of Nursing, Harbin Medical University (Daqing), Daqing, Heilongjiang Province, People’s Republic of China
| | - Qiuxue Sun
- School of Nursing, Harbin Medical University (Daqing), Daqing, Heilongjiang Province, People’s Republic of China
| | - Juan Li
- Department of Pneumology, Qingdao Hospital of Traditional Chinese Medicine, Qingdao, Shangdong Province, People’s Republic of China
| | - Wenyue Zhang
- Department of Rehabilitation, People’s Hospital of Daqing, Daqing, Heilongjiang Province, People’s Republic of China
| | - Yudi He
- School of Nursing, Harbin Medical University (Daqing), Daqing, Heilongjiang Province, People’s Republic of China
| | - Yuqiu Zhou
- School of Nursing, Harbin Medical University (Daqing), Daqing, Heilongjiang Province, People’s Republic of China
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Hernández-Méndez B, Martín-Silva I, Tapias-Vilanova M, Moreno-Gallo Y, Sanjuan-Menendez E, Lorenzo-Tamayo E, Ramos-González M, Montufo-Rosal M, Zuriguel-Pérez E. Very early mobilization in the stroke unit: Functionality, quality of life and disability at 90 days and 1 year post-stroke. NeuroRehabilitation 2021; 49:403-414. [PMID: 34308915 DOI: 10.3233/nre-210118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The evidence of early mobilization after stroke is conflicting, and the recovery period is an important concern. OBJECTIVE To analyse the functionality, quality of life and disability at 90 days and 1 year post-stroke of patients who received a Very Early Mobilization Protocol (VEMP). METHODS Prospective cohort study in a tertiary stroke unit. Consecutive patients aged≥18 years and without prior significant disability, who presented motor deficit after acute stroke, were included. A symmetry test was performed to compare the changes in the main variables: Barthel Index (BI), Functional Ambulation Category (FAC), modified Rankin Scale (mRS) and EuroQol five-dimensions three-level (EQ-5D-3L) between 90 days and 1 year post-stroke. RESULTS A total of 123 patients were recruited. The BI reflected an improvement at 1 year in transfer to chair/bed in 25.8%(p < 0.01) of patients and in toilet use in 25.8%(p = 0.02). The FAC showed an improvement at 1 year in 44.4%(p < 0.01) of patients and the mRS in 19.1%(p = 0.01). The usual activities dimension of the EQ-5D-3L showed a clinically relevant improvement after 1 year in 15.9%(p = 0.23) of patients. CONCLUSIONS A significant percentage of patients show improvements in some functional areas and in disability between 90 days and 1 year post-stroke.
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Affiliation(s)
- Beatriz Hernández-Méndez
- Rehabilitation Service/Physiotherapy and Occupational Therapy Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain.,Multidisciplinary Nursing Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Isabel Martín-Silva
- Rehabilitation Service/Physiotherapy and Occupational Therapy Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Martíi Tapias-Vilanova
- Rehabilitation Service/Physiotherapy and Occupational Therapy Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Yolanda Moreno-Gallo
- Rehabilitation Service/Physiotherapy and Occupational Therapy Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Estela Sanjuan-Menendez
- Neurology Service/Stroke Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain.,Stroke Research, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Eva Lorenzo-Tamayo
- Neurology Service/Stroke Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Montserrat Ramos-González
- Neurology Service/Stroke Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Marina Montufo-Rosal
- Neurology Service/Stroke Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
| | - Esperanza Zuriguel-Pérez
- Multidisciplinary Nursing Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron, Barcelona, Spain
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10
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Sandberg K, Kleist M, Wijkman M, Enthoven P. Effects of In-Bed Cycle Exercise in Patients With Acute Stroke: A Randomized Controlled Trial. Arch Rehabil Res Clin Transl 2020; 2:100085. [PMID: 33543108 PMCID: PMC7853346 DOI: 10.1016/j.arrct.2020.100085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Objective To investigate the effects of in-bed cycle exercise in addition to usual care in patients with acute stroke, National Institutes of Health Stroke Scale (NIHSS) 7-42, regarding walking ability, functional outcomes, and inpatient care days. Design Randomized controlled trial. Setting Hospital care. Participants Patients (N=56) with stroke NIHSS 7-42 were recruited 24-48 hours after stroke onset from 2 stroke units in Sweden. Interventions Both groups received usual care. The intervention group also received 20 minutes bed cycling 5 days per week with a maximum of 15 sessions. Main Outcome Measures The primary outcome was median change in walking ability measured with the 6-minute walk test (6MWT). Secondary outcome measures included the median change in modified Rankin Scale (mRS), Barthel Index (BI) for activities of daily living, and inpatient care days. Measurements were performed at baseline, post intervention (3 weeks), and at 3-month follow-up. Results There was no significant difference in change of walking ability (6MWT) from baseline to follow-up between the intervention and control groups (median, 105m [interquartile range [IQR, 220m] vs 30m [IQR, 118m], respectively, P=.147, d=0.401). There were no significant differences between groups regarding mRS, BI, or inpatient care days. Patients with less serious stroke (NIHSS 7-12) seemed to benefit from the intervention. Conclusion Although this study may have been underpowered, patients with stroke NIHSS 7-42 did not benefit from in-bed cycle exercise in addition to usual care after acute stroke. A larger study is needed to confirm our results.
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Affiliation(s)
- Klas Sandberg
- Department of Rehabilitation Vrinnevi Hospital, Norrköping, Sweden.,Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Marie Kleist
- Department of Rehabilitation Vrinnevi Hospital, Norrköping, Sweden.,Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Magnus Wijkman
- Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden.,Department of Internal Medicine, Vrinnevi Hospital, Norrköping, Sweden
| | - Paul Enthoven
- Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
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Riberholt CG, Wagner V, Lindschou J, Gluud C, Mehlsen J, Møller K. Early head-up mobilisation versus standard care for patients with severe acquired brain injury: A systematic review with meta-analysis and Trial Sequential Analysis. PLoS One 2020; 15:e0237136. [PMID: 32790771 PMCID: PMC7425882 DOI: 10.1371/journal.pone.0237136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/20/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND There is increasing focus on earlier rehabilitation in patients with traumatic or hypoxic brain injury or stroke. This systematic review evaluates the benefits and harms of early head-up mobilisation versus standard care in patients with severe acquired brain injury. METHODS We searched Medline, CENTRAL, EMBASE, four other databases and 13 selected clinical trial registries until April 2020. Eligible randomised clinical trials compared early head-up mobilisation versus standard care in patients with severe acquired brain injury and were analysed conducting random- and fixed-effects meta-analyses and Trial Sequential Analysis (TSA). Certainty of evidence was assessed by GRADE. MAIN RESULTS We identified four randomised clinical trials (total n = 385 patients) with severe acquired brain injury (stroke 86% and traumatic brain injury 13%). Two trials were at low risk and two at high risk of bias. We found no evidence of a difference between early mobilisation vs. standard care on mortality or poor functional outcome at end of the intervention (relative risk (RR) 1.19, 95% CI 0.93 to 1.53; I2 0%; very low certainty) or at maximal follow-up (RR 1.03, 95% CI 0.89 to 1.21; I2 0%; very low certainty). We found evidence against an effect on quality of life at maximal follow-up. The proportion of patients with at least one serious adverse event did not differ at end of intervention or at maximal follow-up. For most comparisons, TSA suggested that further trials are needed. CONCLUSIONS We found no evidence of a difference between early mobilisation versus standard care for patients with severe acquired brain injury. Early mobilisation appeared not to exert a major impact on quality of life. This systematic review highlights the insufficient evidence in patients with severe brain injury, and no firm conclusions can be drawn from these data. TRIAL REGISTRATION Protocol uploaded to PROSPERO: April 2018 (revised October 2018, CRD42018088790).
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Affiliation(s)
- Christian Gunge Riberholt
- Department of Neurorehabilitation, Traumatic Brain Injury, Rigshospitalet, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Healthcare Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Wagner
- Department of Neurorehabilitation, Traumatic Brain Injury, Rigshospitalet, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Mehlsen
- Surgical Pathophysiology Unit, Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Clinical Medicine, Faculty of Healthcare Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neuroanaesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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12
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Rethnam V, Langhorne P, Churilov L, Hayward KS, Herisson F, Poletto SR, Tong Y, Bernhardt J. Early mobilisation post-stroke: a systematic review and meta-analysis of individual participant data. Disabil Rehabil 2020; 44:1156-1163. [PMID: 32673130 DOI: 10.1080/09638288.2020.1789229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE To investigate the safety and efficacy of early mobilisation (EM) compared to usual care by meta-analysing individual participant data (IPD). MATERIALS AND METHODS IPD were sought from randomised controlled trials comparing out-of-bed mobilisation starting within 48 h from stroke onset to usual care for acute stroke patients. Six trials were sourced from a recent Cochrane review. Favourable outcome (modified Rankin Scale 0-2) and death at 3 months post-stroke were compared between both groups using mixed-effect logistic regression modelling. Adjusted odds ratios (aORs) with respective 95% confidence intervals (95%CI) were reported. RESULTS Out of 2630 participants, 1437 (54.6%) were assigned to EM and 1193 (45.4%) to usual care. Intervention protocols varied considerably between trials. The median (interquartile range) delay to starting mobilisation post-stroke onset was 20 h (14.5-23.8) for EM and 23 h (16.7-34.3) for usual care group. Fewer EM participants had a favourable outcome at 3 months post-stroke compared to the usual care group (678 [48%] vs. 611 [52%]; aOR = 0.75, 95%CI: 0.62-0.92, p = 0.005). No difference in death at 3 months post-stroke between EM and usual care was observed (102 [7%] vs. 84 [7%]; aOR = 1.46, 95%CI: 0.92-2.31, p = 0.108). CONCLUSION The commencement of mobilisation should only be considered after 24 h post-stroke. Further research is required to identify safe, optimal dose, and timing of EM post-stroke.IMPLICATIONS FOR REHABILITATIONPatients who commenced mobilisation early after stroke had worse outcome than usual care.Insufficient detail about mobilisation interventions or usual care in many studies limits any further interpretation.The commencement of mobilisation should only be considered after 24-h post-stroke.
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Affiliation(s)
- Venesha Rethnam
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Australia.,NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, Royal Infirmary, Glasgow, UK
| | - Leonid Churilov
- NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia.,Melbourne Medical School, University of Melbourne, Parkville, Australia
| | - Kathryn S Hayward
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Australia.,NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia.,Melbourne School of Health Sciences, University of Melbourne, Parkville, Australia
| | - Fanny Herisson
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Simone R Poletto
- Clinical School of Physiotherapy, Lutheran University of Brazil, Canoas, Brazil
| | - Yanna Tong
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Beijing, China
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Australia.,NHMRC Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, Australia
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Denissen S, Staring W, Kunkel D, Pickering RM, Lennon S, Geurts ACH, Weerdesteyn V, Verheyden GSAF. Interventions for preventing falls in people after stroke. Cochrane Database Syst Rev 2019; 10:CD008728. [PMID: 31573069 PMCID: PMC6770464 DOI: 10.1002/14651858.cd008728.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Falls are one of the most common complications after stroke, with a reported incidence ranging between 7% in the first week and 73% in the first year post stroke. This is an updated version of the original Cochrane Review published in 2013. OBJECTIVES To evaluate the effectiveness of interventions aimed at preventing falls in people after stroke. Our primary objective was to determine the effect of interventions on the rate of falls (number of falls per person-year) and the number of fallers. Our secondary objectives were to determine the effects of interventions aimed at preventing falls on 1) the number of fall-related fractures; 2) the number of fall-related hospital admissions; 3) near-fall events; 4) economic evaluation; 5) quality of life; and 6) adverse effects of the interventions. SEARCH METHODS We searched the trials registers of the Cochrane Stroke Group (September 2018) and the Cochrane Bone, Joint and Muscle Trauma Group (October 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 9) in the Cochrane Library; MEDLINE (1950 to September 2018); Embase (1980 to September 2018); CINAHL (1982 to September 2018); PsycINFO (1806 to August 2018); AMED (1985 to December 2017); and PEDro (September 2018). We also searched trials registers and checked reference lists. SELECTION CRITERIA Randomised controlled trials of interventions where the primary or secondary aim was to prevent falls in people after stroke. DATA COLLECTION AND ANALYSIS Two review authors (SD and WS) independently selected studies for inclusion, assessed trial quality and risk of bias, and extracted data. We resolved disagreements through discussion, and contacted study authors for additional information where required. We used a rate ratio and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person-year) between intervention and control groups. For risk of falling we used a risk ratio and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate and applied GRADE to assess the quality of the evidence. MAIN RESULTS We included 14 studies (of which six have been published since the first version of this review in 2013), with a total of 1358 participants. We found studies that investigated exercises, predischarge home visits for hospitalised patients, the provision of single lens distance vision glasses instead of multifocal glasses, a servo-assistive rollator and non-invasive brain stimulation for preventing falls.Exercise compared to control for preventing falls in people after strokeThe pooled result of eight studies showed that exercise may reduce the rate of falls but we are uncertain about this result (rate ratio 0.72, 95% CI 0.54 to 0.94, 765 participants, low-quality evidence). Sensitivity analysis for single exercise interventions, omitting studies using multiple/multifactorial interventions, also found that exercise may reduce the rate of falls (rate ratio 0.66, 95% CI 0.50 to 0.87, 626 participants). Sensitivity analysis for the effect in the chronic phase post stroke resulted in little or no difference in rate of falls (rate ratio 0.58, 95% CI 0.31 to 1.12, 205 participants). A sensitivity analysis including only studies with low risk of bias found little or no difference in rate of falls (rate ratio 0.88, 95% CI 0.65 to 1.20, 462 participants). Methodological limitations mean that we have very low confidence in the results of these sensitivity analyses.For the outcome of number of fallers, we are very uncertain of the effect of exercises compared to the control condition, based on the pooled result of 10 studies (risk ratio 1.03, 95% CI 0.90 to 1.19, 969 participants, very low quality evidence). The same sensitivity analyses as described above gives us very low certainty that there are little or no differences in number of fallers (single interventions: risk ratio 1.09, 95% CI 0.93 to 1.28, 796 participants; chronic phase post stroke: risk ratio 0.94, 95% CI 0.73 to 1.22, 375 participants; low risk of bias studies: risk ratio 0.96, 95% CI 0.77 to 1.21, 462 participants).Other interventions for preventing falls in people after strokeWe are very uncertain whether interventions other than exercise reduce the rate of falls or number of fallers. We identified very low certainty evidence when investigating the effect of predischarge home visits (rate ratio 0.85, 95% CI 0.43 to 1.69; risk ratio 1.48, 95% CI 0.71 to 3.09; 85 participants), provision of single lens distance glasses to regular wearers of multifocal glasses (rate ratio 1.08, 95% CI 0.52 to 2.25; risk ratio 0.74, 95% CI 0.47 to 1.18; 46 participants) and a servo-assistive rollator (rate ratio 0.44, 95% CI 0.16 to 1.21; risk ratio 0.44, 95% CI 0.16 to 1.22; 42 participants).Finally, transcranial direct current stimulation (tDCS) was used in one study to examine the effect on falls post stroke. We have low certainty that active tDCS may reduce the number of fallers compared to sham tDCS (risk ratio 0.30, 95% CI 0.14 to 0.63; 60 participants). AUTHORS' CONCLUSIONS At present there exists very little evidence about interventions other than exercises to reduce falling post stroke. Low to very low quality evidence exists that this population benefits from exercises to prevent falls, but not to reduce number of fallers.Fall research does not in general or consistently follow methodological gold standards, especially with regard to fall definition and time post stroke. More well-reported, adequately-powered research should further establish the value of exercises in reducing falling, in particular per phase, post stroke.
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Affiliation(s)
- Stijn Denissen
- KU LeuvenDepartment of Rehabilitation SciencesLeuvenBelgium
- Vrije Universiteit BrusselCIME Cognition and Modeling group, Center For Neurosciences (C4N)BrusselsBelgium1050
| | - Wouter Staring
- Radboud University Medical CentreDepartment of Rehabilitation, Donders Institute for Brain, Cognition and BehaviourNijmegenNetherlands
| | - Dorit Kunkel
- University of SouthamptonFaculty of Health SciencesSouthampton General HospitalMP 886, Tremona RoadSouthamptonUKSO16 6YD
| | - Ruth M Pickering
- University of SouthamptonDepartment of Public Health Sciences and Medical StatisticsSouthampton General Hospital, MP 805Tremona RoadSouthamptonUKSO16 6YD
| | - Sheila Lennon
- Flinders UniversityPhysiotherapy, College of Nursing & Health SciencesAdelaideAustralia
| | - Alexander CH Geurts
- Radboud University Medical CentreDepartment of Rehabilitation, Donders Institute for Brain, Cognition and BehaviourNijmegenNetherlands
- Sint Maartenskliniek ResearchNijmegenNetherlands
| | - Vivian Weerdesteyn
- Radboud University Medical CentreDepartment of Rehabilitation, Donders Institute for Brain, Cognition and BehaviourNijmegenNetherlands
- Sint Maartenskliniek ResearchNijmegenNetherlands
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Alamri MS, Waked IS, Amin FM, Al-Quliti KW, Manzar MD. Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit. ACTA ACUST UNITED AC 2019; 24:81-88. [PMID: 31056538 PMCID: PMC8015460 DOI: 10.17712/nsj.2019.2.20180004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Objectives: To evaluate the effectiveness of an early mobility protocol for stroke patients in the intensive care unit. Methods: Participants were patients with first or recurrent stroke (n=60, age=49.02±6.36 years, body mass index=32.95±5.67 kg/m2) admitted to the intensive care stroke unit in general hospitals, Riyadh during October and December 2016. Single group pretest-posttest design involving an early mobility protocol was started within first 24 hours admission. Pre and post measurements of muscle strength, pulmonary function and quality of life were carried out. Results: There were significant improvements in muscle strength of upper and lower extremities´ muscles after treatment (p<0.05), pulmonary functions including Forced Vital Capacity, Forced Expiratory Volume 1 (p<0.05) and quality of life, namely, Barthel Index and modified Rankin Scale (p<0.01). Conclusion: This study demonstrates that initiating an early mobility protocol is safe and effective for intensive care unit stroke patients and supports introducing the current protocol as a standard protocol in neurogenic Intensive Care Units.
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Affiliation(s)
- Majed S Alamri
- Department of Nursing, College of Applied Medical Sciences, Majmaah University, Majmaah, Kingdom of Saudi Arabia. E-mail:
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Langhorne P, Collier JM, Bate PJ, Thuy MNT, Bernhardt J. Very early versus delayed mobilisation after stroke. Cochrane Database Syst Rev 2018; 10:CD006187. [PMID: 30321906 PMCID: PMC6517132 DOI: 10.1002/14651858.cd006187.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Very early mobilisation (VEM) is performed in some stroke units and recommended in some acute stroke clinical guidelines. However, it is unclear whether very early mobilisation independently improves outcome after stroke. OBJECTIVES To determine whether very early mobilisation (started as soon as possible, and no later than 48 hours after onset of symptoms) in people with acute stroke improves recovery (primarily the proportion of independent survivors) compared with usual care. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched 31 July 2017). We also systematically searched 19 electronic databases including; CENTRAL; 2017, Issue 7 in the Cochrane Library (searched July 2017), MEDLINE Ovid (1950 to August 2017), Embase Ovid (1980 to August 2017), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to August 2017) , PsycINFO Ovid (1806 to August 2017), AMED Ovid (Allied and Complementary Medicine Database), SPORTDiscus EBSCO (1830 to August 2017). We searched relevant ongoing trials and research registers (searched December 2016), the Chinese medical database, Wanfangdata (searched to November 2016), and reference lists, and contacted researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of people with acute stroke, comparing an intervention group that started out-of-bed mobilisation within 48 hours of stroke, and aimed to reduce time-to-first mobilisation, with or without an increase in the amount or frequency (or both) of mobilisation activities, with usual care, where time-to-first mobilisation was commenced later. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data, assessed risk of bias, and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death or poor outcome (dependency or institutionalisation) at the end of scheduled follow-up. Secondary outcomes included death, dependency, institutionalisation, activities of daily living (ADL), extended ADL, quality of life, walking ability, complications (e.g. deep vein thrombosis), patient mood, and length of hospital stay. We also analysed outcomes at three-month follow-up. MAIN RESULTS We included nine RCTs with 2958 participants; one trial provided most of the information (2104 participants). The median (range) delay to starting mobilisation after stroke onset was 18.5 (13.1 to 43) hours in the VEM group and 33.3 (22.5 to 71.5) hours in the usual care group. The median difference within trials was 12.7 (4 to 45.6) hours. Other differences in intervention varied between trials; in five trials, the VEM group were also reported to have received more time in therapy, or more mobilisation activity.Primary outcome data were available for 2542 of 2618 (97.1%) participants randomized and followed up for a median of three months. VEM probably led to similar or slightly more deaths and participants who had a poor outcome, compared with delayed mobilisation (51% versus 49%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.92 to 1.26; P = 0.36; 8 trials; moderate-quality evidence). Death occurred in 7% of participants who received delayed mobilisation, and 8.5% of participants who received VEM (OR 1.27, 95% CI 0.95 to 1.70; P = 0.11; 8 trials, 2570 participants; moderate-quality evidence), and the effects on experiencing any complication were unclear (OR 0.88; 95% CI 0.73 to 1.06; P = 0.18; 7 trials, 2778 participants; low-quality evidence). Analysis using outcomes collected only at three-month follow-up did not alter the conclusions.The mean ADL score (measured at end of follow-up, with the 20-point Barthel Index) was higher in those who received VEM compared with the usual care group (mean difference (MD) 1.94, 95% CI 0.75 to 3.13, P = 0.001; 8 trials, 9 comparisons, 2630/2904 participants (90.6%); low-quality evidence), but there was substantial heterogeneity (93%). Effect sizes were smaller for outcomes collected at three-month follow-up, rather than later.The mean length of stay was shorter in those who received VEM compared with the usual care group (MD -1.44, 95% CI -2.28 to -0.60, P = 0.0008; 8 trials, 2532/2618 participants (96.7%); low-quality evidence). Confidence in the answer was limited by the variable definitions of length of stay. The other secondary outcome analyses (institutionalisation, extended activities of daily living, quality of life, walking ability, patient mood) were limited by lack of data.Sensitivity analyses by trial quality: none of the outcome conclusions were altered if we restricted analyses to trials with the lowest risk of bias (based on method of randomization, allocation concealment, completeness of follow-up, and blinding of final assessment), or information about the amount of mobilisation.Sensitivity analysis by intervention characteristics: analyses restricted to trials where the mean VEM time-to-first mobilisation was less than 24 hours, showed an odds of death of 1.35 (95% CI 0.99 to 1.83; P = 0.06; I² = 25%; 5 trials). Analyses restricted to the trials that clearly reported a more prolonged out-of-bed activity showed a similar primary outcome (OR 1.14; 0.96 to 1.35; P = 0.13; I² = 28%; 5 trials), and odds of death (OR 1.27; 0.93 to 1.73; P = 0.13; I² = 0%; 4 trials) to the main analysis.Exploratory network meta-analysis (NMA): we were unable to analyze by the amount of therapy, but low-quality evidence indicated that time-to-first mobilisation at around 24 hours was associated with the lowest odds of death or poor outcome, compared with earlier or later mobilisation. AUTHORS' CONCLUSIONS VEM, which usually involved first mobilisation within 24 hours of stroke onset, did not increase the number of people who survived or made a good recovery after their stroke. VEM may have reduced the length of stay in hospital by about one day, but this was based on low-quality evidence. Based on the potential hazards reported in the single largest RCT, the sensitivity analysis of trials commencing mobilisation within 24 hours, and the NMA, there was concern that VEM commencing within 24 hours may carry an increased risk, at least in some people with stroke. Given the uncertainty around these effect estimates, more detailed research is still required.
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Affiliation(s)
- Peter Langhorne
- ICAMS, University of GlasgowAcademic Section of Geriatric MedicineLevel 2, New Lister BuildingGlasgow Royal InfirmaryGlasgowUKG31 2ER
| | - Janice M Collier
- National Stroke Research InstituteVery Early Rehabilitation Stroke Research ProgramLevel 1, Neurosciences BuildingARMC Repat Campus, 300 Waterdale RoadHeidelberg HeightsVictoriaAustralia3081
| | | | - Matthew NT Thuy
- Austin HealthNational Stroke Research InstituteLevel 1, Neurosciences BuildingAustin Health, Repatriation Campus, 300 Waterdale RdHeidelberg HeightsVictoriaAustralia3081
| | - Julie Bernhardt
- Florey Institute of Neuroscience and Mental Health245 Burgundy StreetHeidelbergVictoriaAustralia3081
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Langhorne P, Wu O, Rodgers H, Ashburn A, Bernhardt J. A Very Early Rehabilitation Trial after stroke (AVERT): a Phase III, multicentre, randomised controlled trial. Health Technol Assess 2018; 21:1-120. [PMID: 28967376 DOI: 10.3310/hta21540] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Mobilising patients early after stroke [early mobilisation (EM)] is thought to contribute to the beneficial effects of stroke unit care but it is poorly defined and lacks direct evidence of benefit. OBJECTIVES We assessed the effectiveness of frequent higher dose very early mobilisation (VEM) after stroke. DESIGN We conducted a parallel-group, single-blind, prospective randomised controlled trial with blinded end-point assessment using a web-based computer-generated stratified randomisation. SETTING The trial took place in 56 acute stroke units in five countries. PARTICIPANTS We included adult patients with a first or recurrent stroke who met physiological inclusion criteria. INTERVENTIONS Patients received either usual stroke unit care (UC) or UC plus VEM commencing within 24 hours of stroke. MAIN OUTCOME MEASURES The primary outcome was good recovery [modified Rankin scale (mRS) score of 0-2] 3 months after stroke. Secondary outcomes at 3 months were the mRS, time to achieve walking 50 m, serious adverse events, quality of life (QoL) and costs at 12 months. Tertiary outcomes included a dose-response analysis. DATA SOURCES Patients, outcome assessors and investigators involved in the trial were blinded to treatment allocation. RESULTS We recruited 2104 (UK, n = 610; Australasia, n = 1494) patients: 1054 allocated to VEM and 1050 to UC. Intervention protocol targets were achieved. Compared with UC, VEM patients mobilised 4.8 hours [95% confidence interval (CI) 4.1 to 5.7 hours; p < 0.0001] earlier, with an additional three (95% CI 3.0 to 3.5; p < 0.0001) mobilisation sessions per day. Fewer patients in the VEM group (n = 480, 46%) had a favourable outcome than in the UC group (n = 525, 50%) (adjusted odds ratio 0.73, 95% CI 0.59 to 0.90; p = 0.004). Results were consistent between Australasian and UK settings. There were no statistically significant differences in secondary outcomes at 3 months and QoL at 12 months. Dose-response analysis found a consistent pattern of an improved odds of efficacy and safety outcomes in association with increased daily frequency of out-of-bed sessions but a reduced odds with an increased amount of mobilisation (minutes per day). LIMITATIONS UC clinicians started mobilisation earlier each year altering the context of the trial. Other potential confounding factors included staff patient interaction. CONCLUSIONS Patients in the VEM group were mobilised earlier and with a higher dose of therapy than those in the UC group, which was already early. This VEM protocol was associated with reduced odds of favourable outcome at 3 months cautioning against very early high-dose mobilisation. At 12 months, health-related QoL was similar regardless of group. Shorter, more frequent mobilisation early after stroke may be associated with a more favourable outcome. FUTURE WORK These results informed a new trial proposal [A Very Early Rehabilitation Trial - DOSE (AVERT-DOSE)] aiming to determine the optimal frequency and dose of EM. TRIAL REGISTRATION The trial is registered with the Australian New Zealand Clinical Trials Registry number ACTRN12606000185561, Current Controlled Trials ISRCTN98129255 and ISRCTN98129255. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 54. See the NIHR Journals Library website for further project information. Funding was also received from the National Health and Medical Research Council Australia, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, and the Stroke Association. In addition, National Health and Medical Research Council fellowship funding was provided to Julie Bernhardt (1058635), who also received fellowship funding from the Australia Research Council (0991086) and the National Heart Foundation (G04M1571). The Florey Institute of Neuroscience and Mental Health, which hosted the trial, acknowledges the support received from the Victorian Government via the Operational Infrastructure Support Scheme.
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Affiliation(s)
- Peter Langhorne
- Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Helen Rodgers
- Institute for Ageing and Health, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Ashburn
- Rehabilitation Research Unit, Southampton General Hospital, Southampton, UK
| | - Julie Bernhardt
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
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Li Z, Zhang X, Wang K, Wen J. Effects of Early Mobilization after Acute Stroke: A Meta-Analysis of Randomized Control Trials. J Stroke Cerebrovasc Dis 2018; 27:1326-1337. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/02/2017] [Accepted: 12/17/2017] [Indexed: 02/01/2023] Open
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Xu T, Yu X, Ou S, Liu X, Yuan J, Chen Y. Efficacy and Safety of Very Early Mobilization in Patients with Acute Stroke: A Systematic Review and Meta-analysis. Sci Rep 2017; 7:6550. [PMID: 28747763 PMCID: PMC5529532 DOI: 10.1038/s41598-017-06871-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 06/20/2017] [Indexed: 01/20/2023] Open
Abstract
Whether very early mobilization (VEM) improves outcomes in stroke patients and reduces immobilization-related complications (IRCs) is currently unknown. The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of VEM in acute stroke patients following admission. Medline, Embase, and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that examined the efficacy or safety of VEM in patients with acute stroke. VEM was defined as out of bed activity commencing within 24 or 48 hours after the onset of stroke. A total of 9 RCTs with 2,803 participants were included. Upon analysis, VEM was not associated with favorable functional outcomes (modified Ranking Scale: 0–2) at 3 months [relative risk (RR): 0.96; 95% confidence interval (CI): 0.86–1.06]; VEM did not reduce the risk of IRCs during follow up. With respect to safety outcomes, VEM was not associated with a higher risk of death (RR: 1.04; 95% CI: 0.52–2.09) and did not increase the risk of neurological deterioration or incidence of falls with injury. In conclusion, pooled data from RCTs concluded that VEM is not associated with beneficial effects when carried out in patients 24 or 48 hours after the onset of a stroke.
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Affiliation(s)
- Tao Xu
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Xinyuan Yu
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Shu Ou
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Xi Liu
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Jinxian Yuan
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Yangmei Chen
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China.
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Lynch EA, Cumming T, Janssen H, Bernhardt J. Early Mobilization after Stroke: Changes in Clinical Opinion Despite an Unchanging Evidence Base. J Stroke Cerebrovasc Dis 2016; 26:1-6. [PMID: 27612626 DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/11/2016] [Accepted: 08/12/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND We sought to determine whether Australasian health professionals' opinions regarding early mobilization after stroke changed between 2008 and 2014, when a large international trial of early mobilization (A Very Early Rehabilitation Trial, AVERT) was underway. METHODS Attendees at the two major Australasian stroke conferences in 2008 and 2014 were surveyed. Participants rated their agreement with statements about the risks and benefits of commencing mobilization within 24 hours of hemorrhagic and ischemic stroke using a 5-point Likert scale. Participants in 2014 were asked about their awareness of AVERT. Logistic regressions were performed to determine whether the time point (2008 versus 2014) or awareness of AVERT influenced opinions about early mobilization. RESULTS Surveys were completed by 443 health professionals (2008: N = 202; 2014: N = 241). Most respondents in 2014 reported that early mobilization was beneficial and not harmful to people with ischemic and hemorrhagic stroke. Opinions regarding mobilization after ischemic stroke did not change significantly between 2008 and 2014. In 2014, a significantly greater proportion of respondents believed that early mobilization after hemorrhagic stroke was helpful (2008: n = 98 of 202 [49%] versus 2014: n = 170 of 241 [71%], P < .01). Awareness of AVERT was significantly associated with the opinion that early mobilization was beneficial and not harmful to patients with stroke (P < .05). CONCLUSIONS Australasian health professionals' opinions of early mobilization after hemorrhagic stroke changed between 2008 and 2014, prior to reporting of the AVERT trial. Our results suggest that awareness of an ongoing research trial can lead to changes in opinions before the efficacy of the experimental intervention is known.
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Affiliation(s)
- Elizabeth A Lynch
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.
| | - Toby Cumming
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Heidi Janssen
- Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Hunter Medical Research Institute, University of Newcastle, Callaghan, New South Wales, Australia; Hunter Stroke Service, Hunter New England Local Health District, Newcastle, New South Wales, Australia
| | - Julie Bernhardt
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia; Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, The Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
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